1-1870 Decision to disclose

What Could Influence Workers' Decisions to Disclose a Mental Illness at Work?

1Department of Psychiatry and Behavioral Sciences, Department of Public Health Sciences, University of California, Davis, Sacramento, California, USA

2Tilburg School of Social and Behavioral Sciences, Tranzo Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, The Netherlands

3Tilburg School of Social and Behavioral Sciences, Department Human Resource Studies and Tranzo Scientific Center for Care and Wellbeing, Tilburg University, Tilburg, The Netherlands

Correspondence to
Carolyn S. Dewa, MPH, PhD, Department of Psychiatry and Behavioral Sciences, University of California, Davis, 2450 48th Str, Sacramento, California 95817, USA

E-mail: csdewa@ucdavis.edu

Received: Nov 28, 2019

Accepted: Mar 28, 2020

Abstract

Background: Stigma can be a barrier for workers experiencing a mental illness to access accommodations at work. However, work accommodations may be necessary to maintain a worker's ability to work. Therefore, it may be important to develop effective interventions to address workplace stigma.

Objective: To determine (1) what proportion of workers would probably disclose their mental health issue to their manager, (2) what are the motivating factors for the decision of whether or not to disclose, and (3) what would potentially change the disclosure decision?

Methods: A link to a Web-based questionnaire was sent to a nationally representative sample of 1671 Dutch adults over 18 years of age. The response rate was 74%. We focused on the 892 respondents who indicated they were either employed for pay or looking for employment, not in management positions, and never experienced a mental health issue. This group comprised 73% of the total sample. They were asked if they would disclose their mental health issue to their manager. For what reasons would they disclose/not disclose the issue? And, what could change their decision?

Results: We found that almost 75% of workers would disclose to their managers. The perceived relationship with their managers and feelings of responsibility to their workplaces were important contributors to the decision. A large minority of workers would not tell, preferring to deal with their issues alone. In addition, a significant proportion of workers would choose not to disclose fearing negative consequences.

Conclusion: Our results indicate that the majority of these Dutch workers would disclose a mental health issue to their managers. The relationship with the manager plays a central role. The advice from a trusted individual and the experiences of colleagues are also significant factors in the disclosure decision.

Keywords: Social stigma; Mental health; Mental disorders; Disclosure; Workplaces; Occupational groups

Introduction

Stigma of mental illness has been identified as a barrier to help seeking.1-3 In workplace settings, stigma can prevent workers struggling with mental health issues from asking for help because they fear mental illness-related prejudice and discrimination from work colleagues and supervisors.4,5 They are afraid of being exposed to social rejection and harassment.2,6,7

Without disclosing their struggles, workers will however not receive work accommodations although they may need them.5,8 Zwerling, et al,9 reported that US workers experiencing depression are less likely to report receiving work accommodations. In their study, Boot, et al,10 found that while work accommodations are effective in improving work participation, only a third of Dutch workers with mental disorders report receiving accommodations. The reluctance may be related to the fear of exclusion. A recent Dutch study found that managers and human resource professionals support disclosure because it provides useful information with which to screen out potential employees.11

If stigma is a barrier to disclosure because it introduces a risk to employment, addressing stigma in the workplace may be one way to effectively attend to work disability related to mental health issues. Stigma may be perceived in a variety of ways including through organizational policies as well as through interpersonal relationships with managers and colleagues. Therefore, to develop programs to support workers requiring help, it is also important to understand the breadth of the positive and negative factors that affect the decision to disclose. Yet, there is a paucity of studies that have examined the potential factors that affect the disclosure decision.

We conducted the current study to determine (1) what proportion of workers would probably disclose their mental health issue to their manager, (2) what factors contribute to making the decision of whether or not to disclose, and (3) what would potentially change the disclosure decision?

Materials and Methods

Study Population

The data are from the February 2018 Longitudinal Internet Studies for the Social Sciences (LISS) panel that is administered by CentERdata. The panel was constructed through a cooperation of CentERdata and Statistics Netherlands. It is based on a random sample of 10 150 Dutch addresses representing a random sample of 10% of the population. The LISS panel sample consists of 5000 households and 8280 panel members. For this study, a link to a Web-based questionnaire was sent to 1671 Dutch adults aged >18 years who were part of the panel; the response rate was 73.5% (n=1228). There were 1224 respondents who indicated they were in the labor force (ie, were employed for pay or looking for employment) and were not in management positions. This study focused on the disclosure intentions of the 892 workers who indicated they had never experienced mental health issues. This group comprised 73% of the total sample.

Disclosure Variables

Respondents were asked a series of questions based on what they thought they were likely to do if they experienced mental health issues. The questions used in this study were adapted from studies conducted by Brohan, et al,4 and Dewa12 that examined workers' attitudes towards disclosing a mental disorder to their managers. The first question (Q1) asked whether respondents would disclose a mental health issue to their managers (Fig 1).

fig%201r.jpg

Figure 1: Survey questions

Reasons for a Positive Disclosure Decision (Q2a)

The subsequent questions were based on the response to Q1. If there was a positive response to Q1, the respondent was asked the reason for the disclosure decision (Q2a). Responses were assigned to one of two categories: (1) intrinsic factors and (2) extrinsic factors. Intrinsic factors reflected the worker's values and beliefs.13 They included disclosure motivated by a sense of responsibility and positive feelings towards managers. Extrinsic factors were motivated by anticipated reactions of others, incentives offered by the organization or manager, or advice from a trusted source.13 This category included motivation based on the belief that the manager would notice the problem, the positive example others who disclosed and benefitted from disclosing, a recommendation of an occupational health physician, the desire to obtain either work accommodations, treatment during work hours, solutions offered through organizational policies or to prevent having to report sick.

Reasons for a Negative Disclosure Decision (Q2b)

If the answer to Q1 indicated the respondent would not tell their manager, respondents were queried about the reasons for their negative response (Q2b). These responses were aggregated into either: (1) intrinsic factors or (2) extrinsic factors.13 Intrinsic factors included either a preference to deal with the mental health issue alone or discomfort or embarrassment from disclosing. Extrinsic factors included fear of negative career effects, negative impacts on relationships, seeing others had negative experiences, or believing that their work would not be impacted.

Factors Influencing a Change in Decision (Q3)

The final question (Q3) in the series asked respondents, “Finally, what could change your decision to [not] tell your manager?” For the purpose of the analysis, responses were grouped into four categories: (1) no change, (2) advice of a trusted person, (3) manager influence, and (4) experiences of colleagues. The “no change” category indicated respondents would not change their decision. The “advice of a trusted person” category included advice from the occupational health physician, a colleague, or someone from his/her private life. The “change in manager” category included the responses new policy by the manager, manager begins talking about mental health issues, or the manager is replaced. The “experiences of colleagues” category indicated that a change in decision would be influenced by observing what happens to others at work.

Descriptive Variables

Demographic variables studied included sex (male/female), age (<34, 35–44, 45–54, and >55 years), marital status (single/never married, married/cohabiting, divorced/separated/widowed), and educational attainment (≤high school yes/no). Variables were also created to indicate the type of location where the respondent resided: (1) extremely urban (population density >2500/km2), (2) very urban (population density 1500–2500/km2), (3) moderately urban (population density 1000–1500/km2), slightly urban (population density 500–1000/km2), and (4) not urban (population density <500/km2).

Ethics

The study dataset was de-identified by CentERdata. The University of California, Davis' Institutional Review Board approved the study protocol.

Statistical Analyses

χ2 test was used to examine the differences in the distribution of categorical variables in those who indicated they probably would or would not disclose their mental health issue to their manager. A multivariate logistic regression analysis was done to examine the association of having intrinsic only or extrinsic only factors with the decision to disclose (Q1) while controlling for demographic characteristics. χ2 tests were also used to examine the differences in the categorical factors that would change the decision of disclosing their mental health issue to their manager. A p value <0.05 was considered statistically significant.

Results

About 74% of the 892 respondents who had never experienced mental health issues indicated that they probably would disclose a mental health issue to their manager. There were no significant differences in most of the demographic characteristics of those who probably would and would not tell their managers if they had a mental health issue (Table 1). The exception was with educational attainment—those who had a high school degree or less were less likely to indicate that they would disclose (p<0.001).

Table 1: Frequency distribution, n (%), of demographic characteristics of studied participants

Parameter

Would tell the manager (n=656)

Would not tell the manager (n=236)

Total (n=892)

p value

Sex

Male

303 (46.2)

118 (50.0)

421 (47.2)

0.31

Female

353 (53.8)

118 (50.0)

471 (52.8)

Age (yrs) 

≤34

163 (24.9)

60 (25.4)

223 (25.0)

0.93

35–44

148 (22.6)

54 (22.9)

202 (22.7)

45–54

161 (24.5)

53 (22.5)

214 (24.0)

≥55

184 (28.1)

69 (29.2)

253 (28.4)

Marital Status

Married/Co-habiting

459 (70.0)

168 (71.2)

627 (70.3)

0.91

Separated/Divorced/Cohabiting

79 (12.0)

26 (11.0)

105 (11.8)

Single, Never Married

118 (18.0)

42 (17.8)

160 (17.9)

Educational Attainment

High school degree or less

148 (22.6)

80 (33.9)

228 (25.6)

<0.001

More than high school degree

508 (77.4)

156 (66.1)

664 (74.4)

Population Density of Place of Residence (per km2)

>2500

112 (17.2)

47 (20.2)

159 (18.0)

0.36

1500–2500

159 (24.4)

68 (29.2)

227 (25.7)

1000–1500

144 (22.1)

44 (18.9)

188 (21.2)

500–1000

136 (20.9)

41 (17.6)

177 (20.0)

<500

101 (15.5)

33 (14.2)

134 (15.1)

Factors Influencing Disclosure Decision

When demographic characteristics were controlled, those with only intrinsic factors compared to those with a combination of intrinsic and extrinsic factors were significantly more likely to decide to disclose (OR 3.65, 95% CI 2.39 to 5.57) (Table 2).

Table 2: Results of the logistic regression analysis in those who would tell manager

Parameter

OR (95% CI)

Reasons for Decision

Intrinsic reasons

3.65 (2.39 to 5.73)

Extrinsic reasons

1.32 (0.91 to 1.93)

Both intrinsic and extrinsic reasons

1 (Ref)

Sex

Male

1.09 (0.79 to 1.50)

Female

1 (Ref)

Age (yrs)

≤34

1 (Ref)

35–44

1.08 (0.68 to 1.72)

45–54

1.22 (0.76 to 1.96)

≥55

1.14 (0.73 to 1.80)

Marital Status

Married/Co-habiting

1.05 (0.94 to 1.17)

Other

1 (Ref)

Educational Attainment

High school degree or less

0.65 (0.46 to 0.94)

More than high school degree

1 (Ref)

Population Density of Place of Residence (per km2)

>2500

1 (Ref)

1500–2500

0.93 (0.58 to 1.49)

1000–1500

1.56 (0.93 to 2.62)

500–1000

1.65 (0.98 to 2.80)

<500

1.69 (0.94 to 3.01)

Among those who would disclose, there was a significantly larger proportion who indicated intrinsic factors vs extrinsic factors would influence their decision (Table 3). There were no significant differences between which intrinsic factors were endorsed. About two-thirds of those who would disclose identified that a good relationship with their manager and feelings of responsibility to tell would compel their decision.

Table 3: Reasons to disclose and not to disclose

Reasons

n (%, 95% CI)

To disclose

Intrinsic

581 (88.6, 85.9 to 90.9)

Good relationship with manager

391 (59.6, 55.6 to 67.1)

Feel responsible

416 (63.4, 59.6 to 67.1)

Extrinsic

468 (71.3, 67.7 to 74.8)

Seen how others benefited

67 (10.2, 8.0 to 12.8)

Manager would be able to tell

200 (30.5, 27.0 to 34.1)

Obtain work accommodations

160 (24.4, 21.1 to 27.9)

Company doctor

53 (8.1, 6.1 to 10.4)

Prevent having to report sickness absence

226 (34.5, 30.8 to 38.2)

Get time off for treatment during work

159 (24.2, 21.0 to 27.7)

Organizational policies

136 (20.7, 17.7 to 24.0)

Not to disclose

Intrinsic

159 (67.4, 61.0 to 73.3)

Prefer to deal with it alone

140 (59.3, 52.8 to 65.6)

Feel uncomfortable or embarrassed

68 (28.8, 23.1 to 35.0)

Extrinsic

161 (68.2, 61.9 to 74.1)

Fear of negative effect on career

72 (30.5, 24.7 to 36.8)

Fear of losing friendships

5 (2.1, 0.7 to 4.9)

Seen others have negative
experience

33 (14.0, 9.8 to 19.1)

Would not affect work

29 (12.3, 8.4 to 17.2)

Would not want to be treated
differently

81 (34.3, 28.2 to 40.8)

The main extrinsic factors that would positively influence decisions included preventing having to report sickness absence (34.5%), believing the manager would notice that they had a mental health issue (30.5%), accessing work accommodations (24.4%), and needing to get time off work to get treatment (24.2%) (Table 3).

Among those who probably would not disclose, there were no significant differences in the proportion who would endorse intrinsic (67.4%) vs extrinsic (68.2%) factors. Of the intrinsic factors, a significantly larger proportion indicated that preferring to deal with the mental health issue alone (59.3%) would influence their negative disclosure decision (Table 3). Among the extrinsic factors, significant proportions suggested that their decision would be based on the fear that they would be treated differently (34.3%) and their career would be negatively impacted (30.5%).

Factors that Could Change Decision

When asked what could change their disclosure decision, about a third of respondents in both groups (ie, those who would and would not disclose) indicated that they would not change their decision (32.0% and 36.0%) (Table 4). Compared with those who thought they could be influenced from not disclosing to disclosing, there was a significantly larger proportion of those who said that they could be influenced to change from disclosing to not disclosing, who indicated that advice from trusted sources could influence the change (50.6% vs 42.4%). Among the potential advice givers, colleagues played a more significant role in change going from positive to negative than vice versa (17.2% vs 9.3%, p=0.03); ie, colleagues were more likely to dissuade someone from disclosing (Table 4).

Table 4: Factors that could influence disclosure decision

Factor

Would disclose

Would not disclose

p value

Would not change decision

210 (32.0)

85 (36.0)

0.26

Advice of trusted source

332 (50.6)

100 (42.4)

0.03

Company doctor

217 (33.1)

81 (34.3)

0.73

Colleague

113 (17.2)

22 (9.3)

0.004

Someone in private life

188 (28.7)

53 (22.5)

0.066

Change in manager

196 (29.9)

93 (39.4)

0.007

New policy by manager

83 (12.7)

25 (10.6)

0.41

Manager starts talking about mental health issues

97 (14.8)

64 (27.1)

<0.001

Get a new manager

57 (8.7)

16 (6.8)

0.36

Experience of a colleague

213 (32.5)

37 (15.7)

<0.001

A change in the manager was significantly more important for the decision to change from non-disclosure to disclosure than for the other way around (39.4% vs 29.9%, p=0.007). In addition, a manager talking about mental health issues would have a larger impact on change for those who began in the not disclosing group than those who began in the disclosing group (27.1% vs 14.8%, p<0.001). Finally, the negative experience of a colleague had a potentially greater influence on changing the decision from disclosing to not disclosing (32.5% vs 15.7%, p<0.001).

Discussion

Our results indicated that almost 75% of workers would disclose a mental health issue to their managers. This proportion indicating that they would disclose is significantly higher than that found in previous work among Canadian workers.12 This result was consistent with our previous findings in which workers who had experiences with mental health issues chose to disclose to their managers (unpublished data).

Our findings indicated that those with only intrinsic factors were more likely to disclose. Both the perceived relationship with their managers and feelings of responsibility to their workplaces were important contributors to the decision to disclose. These responses reflected those of workers who had actual experiences of mental health issues and did disclose (unpublished data). These were also consistent with findings from other countries.5,12,14 There is substantial evidence that the relationship with the manager plays an important role in the decision. In addition, these results suggested that this relationship could outweigh other environmental factors such as organizational factors, advice from the occupational physician, or obtaining work accommodations. Furthermore, there is evidence that this relationship is important to a positive disclosure experience (unpublished data). This highlights the importance of manager training to create supportive working relationships with their staff.

Our results also indicated that there was a large minority of workers who would not tell because they would prefer to deal with their issues alone. These findings also mirrored the experiences of workers who had experienced a mental health issue and decided not to disclose (unpublished data). Among the workers with lived experience who did not disclose, there was a large proportion who found this a positive experience because they were able to deal with the mental health issues alone and their work performance was not affected (unpublished data). This highlights the complexity of the disclosure decision. By default, workers who are not motivated by stigma may choose not to disclose. This suggests that it may be important to have a disclosure decision tool to help workers make optimal choices about disclosing.15,16

There was also a significant proportion of workers who would choose not to disclose because of fear of negative consequences or embarrassment. These findings suggested that anticipated stigma also plays a role in the decision making process and that there is a role for anti-stigma training for all workers. The responses indicated that workplace anti-stigma training may need to focus on attitude (eg, feelings of embarrassment) as well as discrimination (eg, the treatment of people with mental disorders). There is evidence that training can significantly change attitudes and behavior.17

Our results also suggested that about a third of workers indicated that they would not be persuaded to change their decision. Among those who initially thought they would not disclose, changes in the manager's behavior was the most significant factor to influence a change. In contrast, those who indicated that they would disclose were more likely to be dissuaded by either what they are told by colleagues or what they observed regarding how colleagues were treated.

One of the strengths of this study is that it is one of the first Dutch studies to use a population-based dataset to examine workplace stigma. In addition, the study design allowed participants to participate anonymously. This decreased the risk of social desirability bias. However, there were also data limitations. One of the primary limitations is that the data are based on self-report and a hypothetical situation. Thus, we are not able to observe what workers do in the actual situation. Nevertheless, the responses may offer important insight into the stigma prevalent in the Dutch working environment.

Another limitation is related to the generalizability of the results. The study was conducted in the Netherlands where there is an incentive for employers to prevent disability.18 At the same time, there were respondents who indicated that they would fear disclosing. This suggests that there are Dutch workplaces where stigma exists. The fears that these workers expressed are consistent with those reported in the literature.4

In conclusion, our results indicate that the majority of these Dutch workers would disclose a mental health issue to their managers. Intrinsic (most notably, relationship with managers and feelings of responsibility to tell) factors have significant impacts on the disclosure decision. In the disclosure decision, the relationship with the manager plays a central role. This suggests that if disclosure is one way to prevent work disability related to mental issues, trainings that teach managers skills to be inclusive and supportive are essential to encouraging disclosure and preventing disability. In addition, these findings also indicate there is a place for general trainings for all workplaces that focus on attitudes (eg, feelings of embarrassment) and discrimination (eg, the treatment of people with mental disorders). The advice from a trusted individual and the experiences of colleagues are also significant factors in the disclosure decision.

Conflicts of Interest: None declared.

Financial Support: The Alumni Board of Tilburg University funded the data collection for the special modules used in this research.

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TAKE-HOME MESSAGE

  • Mental health-related workplace stigma can be a barrier to help seeking because it introduces a risk to employment.
  • Addressing mental health-related stigma in the workplace may be one way to effectively attend to work disability related to mental health issues.
  • In the disclosure decision, the relationship with the manager plays a central role.
  • Trainings that teach managers skills to be inclusive and supportive are essential to encouraging disclosure and preventing disability.
  • Advice from a trusted individual and the experiences of colleagues are also significant factors in the disclosure decision.

Cite this article as: Cite this article as: Dewa CS , Van Weeghel J, Joosen MCW, Brouwers EPM. What could influence workers' decisions to disclose a mental illness at work? Int J Occup Environ Med 2020;11:119-127. doi: 10.34172/ijoem.2020.1870




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